Provider Demographics
NPI:1962954206
Name:PROVENCE, MONICA (MA MFT)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:PROVENCE
Suffix:
Gender:F
Credentials:MA MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1429 E 3RD ST APT 8
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-7638
Mailing Address - Country:US
Mailing Address - Phone:323-426-5919
Mailing Address - Fax:
Practice Address - Street 1:201 S SANTA FE AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-4300
Practice Address - Country:US
Practice Address - Phone:323-426-5919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87245106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist